1
Innovative Management: Social Determinant Networks
to Reduce Excessive Hospital Utilization
Session N13, February 11, 2019
Ruben Amarasingham, MD, MBA, President/CEO, Pieces Technologies
2
Ruben Amarasingham, MD, MBA
Dr. Amarasingham is President and CEO of Pieces Technologies,
which provides software and services related to the area of social
determinants of health, which is a subject of this presentation. He
otherwise has no real or apparent conflicts of interest to report.
Conflict of Interest
3
• Overview of the Problem
• Approach to Creating Connected Community and Health System
Networks
• Types of Technology Used Inside and Outside the Health
Systems
• Methods for Deploying Technology to Support the Network
• Results from Connected Community and Health System Networks
Agenda
4
• Outline how to reduce patient admissions using innovative
technology and share clinical patient outcomes
• Discuss the economic perspective of how high admission rates
effect hospitals
• Describe the user perspective on utilizing these technologies
Learning Objectives
5
The Role of Social Determinants in
Health
Adapted From: Booske, B.C., Athens, J.K., Kindig,
D.A., Park, H., & Remington, P.L. (2010). County
Health Rankings [www.countyhealthrankings.org]
6
The Cost of Excess ED and Hospital
Admissions
• CMS: hospital care represented about 30% of the $2.7 trillion in
total expenditures for 2011—the largest share of health care
spending. (1)
• IOM: “unnecessary services” are largest contributor to waste in
US health care, accounting for ~$210 billion of the $750 billion in
excess spending each year (2)
• Non-medical factors including social, behavioral and
environmental determinants of health consistently play a
substantially larger role in hospital use than medical factors (3)
(1) National health expenditures 2011 highlights . Baltimore (MD) : CMS ;2013
(2) Institute of Medicine, Committee on the Learning Health Care System in America In: Smith M, Saunders R, Stuckhardt L, McGinnis JM, eds. Best
Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: National Academies Press (US), 2013.
(3) Chiu et al., 2009; Lee & Paxman, 1997
7
The Problem – Profile from a Homeless
Management CoC
• Over 11,500 clients went to two DFW hospitals in 2 years
• 35% were admitted to the hospital
• 50% of those who went to the ED returned 3 times or more
• 26% of those admitted to the hospital were admitted 3 times or more
• Over 13% of clients are considered high utilizers of ED services
• Shelter clients were ~4 times as likely to be a high utilizer of the ED compared to
other patients
• Cough was most common reason for presenting to the ED
• Clients had a 40% higher readmission rate
• 36% of clients seen in the hospital have hypertension
• 13% of clients seen in the hospital have diabetes mellitus
• 13% of clients seen in the hospital have diabetes mellitus
• 10% of clients seen in the hospital have kidney disease
8
Core Needs
• Crisis and Emergency
• Food Insecurity
• Housing and Utilities
• Interpersonal Violence
• Transportation
Community-Based Organizations (CBOs)
Supplemental Needs
• Family & Social
Supports
• Education
• Employment & Income
• Health Behaviors
• Legal
• Senior service
9
…but CBOs are frequently disconnected,
fragmented, under-capitalized and over-looked.
Community-Based Organizations
Hospitals
How do we align,
connect, and integrate
across social and
health sectors within
communities?
10
• Mixed method approach
• Literature review, Delphi expert
panel, and interviews with
innovative programs to develop a
maturity rubric for communities
participating in these types of
efforts
• National, semi-qualitative surveys
and interviews of 64 communities
and organizations, including our
stakeholders in Dallas, to identify
phenotypes, challenges and
solutions
Study: Cross Sector Partnerships
11
Key Findings: Program Types
12
Many programs are grant funded and
may not be sustainable after the grant
funding is complete. Cost savings and
improvement in outcomes may be difficult
to sustain after the initial “low hanging
fruits”.
Solutions Identified:
• Payment reform around transitional
care activities and population health has
been critical.
• Coalition of CBOs establishing
alignment with hospital strategic plans.
Challenge #1: Sustainability
13
Many programs lack the infrastructure and know-how to
define and measure the most relevant outcomes and to
accurately estimate cost savings.
Solutions Identified:
• Establishing a common data dictionary and data set
requirements across hospitals, health systems,
community based organizations with a common
methodology for analysis.
Challenge #2: Accurate and Timely
Measurement
14
Limited mechanisms and
knowledge on how to share savings.
Solutions Identified:
• Identification of local
philanthropies, foundation and
trusts that would provide funding
to accelerate experimentation
around financial partnerships.
• Partner around areas of health
system penalties or incentives
aligned with a CBO’s specific
core competency.
Challenge #3: Sharing of Savings
15
• Many CBOs lack a technical platform, the infrastructure and the
know-how to integrate data from different sources, such as EMR,
claims data, data from CBOs, and HIEs.
• Many programs lack the infrastructure to consult multiple data
sources during the healthcare or social services provision; so
services are not well coordinated
Challenge #4: CBO Data & Technology
Expertise
Solutions Identified:
• Utilize in work-flow case management systems at the CBO level
that could integrate with EMR systems
• Hospitals have tremendous data and technology expertise, that
can serve as data anchors for community efforts.
16
Programs struggle to define cross-
sector,multi-organization, clinical and
social workflows.
Solutions Identified:
• Increasing demonstration grants
provide critical support to experiment
and establish this evidence base
• National collaboratives and learning
networks
• Information clearing-houses to extract
maximum value on significant but
isolated experimentation occurring
across the country
Challenge #5: Cross-sector workflow
evidence base
17
1. How do you make these network efforts sustainable?
2. How do you build a whole person cross-sector workflow
that works for vastly different users?
3. How do you build a local evidence base? accurate and
timely measurement?
4. How do you get buy in from community partners?
5. How do you deal with community partner data and
technology expertise?
Learnings: Key Questions
18
Creating a Network Connecting Health Systems and
Communities: A SDoH Technology Platform and Services
19
Deploying the Right Technology Inside and
Outside the Hospital
20
The Importance of Leveraging AI Technology to Surface
Real-time Insights from Every Aspect of EMR
21
Approach for Building Community Networks:
Include and Meet All Partners ‘Where They Are’
22
Deploying a Referral and Case Management System
Across the Connected Network
23
Deploying and Integrating in a Variety of Ways is Essential
for Success… Meeting All Stakeholders’ Needs
24
Results – Decreasing Readmissions in a
Connected Network
25
Results – Decreasing Readmissions: All Risk
Groups
26
Results – Decreasing Readmissions: By Payor
Group
27
Results – Identifying Discharge Barriers and
Setting Priorities in Real-Time using NLP
28
Results – Addressing SDoH = Decreased LOS
